Longitudinal study of serpiginous choroiditis and serpiginous like choroiditis using wide field OCT angiography

Purpose: To assess the ability of wide field Swept Source OCTA (SS-OCTA) imaging to detect morphological variations in Serpiginous Choroiditis (SC) and Serpiginous Like Choroiditis (SLC) in response to treatment and also analyze these findings quantitatively using Image J software. Methods: Retrospective observational case series of nine eyes with clinical diagnosis of active SC and SLC, who underwent SS-OCTA and fundus autofluorescence (FAF) imaging at baseline and each follow up visit till 6 months. Morphological analysis was done by two independent graders and quantitative analysis to measure the size and intensity of lesion was done using publicly available Image J software at baseline and each follow up visit. Design: Retrospective observational case series. Results: Using SS-OCTA, all the active lesions followed a characteristic healing pattern. Active lesions appear well defined hypo flow void patches and as healing progressed, lesion became more ill-defined and iso-hyper- intense. Significant increase in mean intensity of the lesion could be apparent after 1 and 6 month of treatment. There was reduction in the size of lesions during follow up however this difference was not statistically significant. Conclusion: SS-OCTA could be a useful noninvasive tool to study the treatment response in SC/SLC both morphologically as well as quantitatively. Quantitative parameters need to be designed in further research studies to aid in uniform management and follow up of uveitis cases.

Classification of Non-Infectious and/or Immune Mediated Cho-Roiditis: A Brief Overview of the Essentials

The choroid was poorly accessible to imaging investigation until the last decade of the last century. With the availability of more precise imaging methods such as indocyanine green angiography (ICGA) and, later, optical coherence tomography (OCT), enhanced depth OCT (EDI-OCT), and OCT angiography (OCTA), appraisal of choroidal inflammation has substantially gained in accuracy. This allowed to precisely determine which structures were touched in the different non-infectious choroiditis entities and made it possible to classify this group of diseases, ICGA signs, mainly hypofluorescent lesions, were identified and described. Previous publications have divided angiographic findings into two main sets of signs: (1) irregular “geographic” hypofluorescent areas corresponding to choriocapillaris non-perfusion and (2) round more regular, hypofluorescent dark dots more evenly distributed in the fundus corresponding to more deep choroidal stromal foci. These distinct findings allowed to subdivide and classify choroiditis into choriocapillaritis and stromal choroiditis. Additional signs were identified from EDI-OCT and OCTA examination supporting the classification of choroiditis into choriocapillaritis and stromal choroiditis. Results: Diseases involving principally the choriocapillaris included Multiple Evanescent White Dot Syndrome (MEWDS), Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE), Idiopathic Multifocal Choroiditis (MFC), and Serpiginous Choroiditis (SC) as well as mixed forms. Diseases primarily involving the choroidal stroma included HLA-A29 Birdshot Retinochoroiditis (BRC), Vogt-Koyanagi-Harada disease (VKH), Sympathetic Ophthalmia (SO), and Sarcoidosis chorioretinitis (SARC). Thanks to new imaging investigations of the choroid, it is now possible to classify and understand the diverse clinicopathological mechanisms in the group of non-infectious choroiditis entities.

A Study to Analyse the Presentation of Autoimmune and Idiopathic Serpiginous Choroiditis in Indian Population

BACKGROUND Serpiginous choroiditis (SC) is an intraocular inflammatory disorder displaying a geographic pattern of choroiditis, extending from the juxtapapillary choroid and intermittently spreading centrifugally. It involves the overlying retinal pigment epithelium (RPE), the outer retina including the choriocapillaries and the choroid.1,2,3 Infectious diseases like tuberculous (TB) uveitis, herpes simplex virus (HSV) uveitis whose fundus changes mimic SC are termed as serpiginous-like choroidopathy (SLC). On slit lamp examination, anterior segment usually appears quiet, non-granulomatous anterior uveitis with mild vitritis and / or fine pigmented cells within the vitreous can be seen. The pattern of fundus involvement varies between the two groups. Fundus fluorescein angiography and indocyanine green angiography (FFA and ICG) are important modalities of investigation that help in differentiating the pattern of involvement and confirming clinical findings. The duration of follow up, reactivation of lesions and complications vary. Hence, it is important to differentiate between SC and SLC for proper diagnosis and appropriate management. The aim of this study is to highlight important features of serpiginous choroiditis and serpiginous like choroidopathy that will aid in the correct diagnosis of these two entities. METHODS This is a retrospective study of 40 patients. Following variables were analysed - age, gender, laterality, visual acuity, and intraocular inflammation through slit lamp examination, pattern of involvement, choroidal-neovascularization, reactivation, clinical investigations and diagnosis. RESULTS 32 patients had serpiginous choroiditis (SC) and eight patients had serpiginous like choroiditis (SLC). Mean age was 50 and 51 years (SC and SLC respectively). Males were predominantly affected (65.5 % in serpiginous choroiditis and 62.5 % in serpiginous like choroiditis). Bilaterality was 80 % in SC-group and 46 % in the SLC-group. Vitreous haze was lesser than or equal to 1 + in SC group. The juxtapapillary-area was involved in 90 % in SC eyes and 0 % in SLC-group. Midperiphery of fundus was involved in 54 % of SLC-group. Reactivation is more common in SLC group than in SC group in a follow up period of one year. Choroidal-neovascularisation was found in two patients only in SLC-group. CONCLUSIONS In cases where vitreous haze is greater than 1 + with unilateral involvement and disease free peripapillary area is present, an infectious aetiology has to be strongly suspected, as an immunomodulatory therapy could have severe consequences. KEYWORDS Serpiginous Choroiditis, Serpiginous like Choroiditis, Autoimmune

Placoid lesions of the retina: progress in multimodal imaging and clinical perspective

Placoid lesions of the retina may be secondary to a wide spectrum of acquired inflammatory conditions that have been reported as single entities with different presentation and clinical course. These conditions include acute posterior multifocal placoid pigment epitheliopathy, persistent placoid maculopathy, serpiginous choroiditis, serpiginous-like choroiditis, relentless placoid chorioretinitis and acute syphilitic posterior placoid chorioretinitis. In this article, we will group these conditions under the name of ‘placoids’. The recognition of the specific condition may be challenging in clinical practice, often resulting in diagnostic and therapeutic delay. Given the complex nature of placoids and their similarities, a systematic approach including differentiating between infectious and non-infectious aetiologies increases the chance of reaching the correct diagnosis. Detailed history and comprehensive clinical examination are the first steps to formulate a diagnostic hypothesis that should be corroborated by multimodal imaging and appropriate investigations. The advent of multimodal imaging has made it possible to extensively study placoids and revealed a constellation of specific findings that may help clinicians in the diagnostic process. The treatment of the conditions other than syphilis is complex and sometimes challenging. Our article is aimed at giving an overview of the individual entities associated with placoids and discussing the differential diagnosis. A practical and systematic approach is then proposed.

Unilateral macular serpiginous-like choroiditis as the initial manifestation of presumed ocular tuberculosis

Background Classic serpiginous choroiditis (SC) usually begins in the peripapillary area and spreads centrifugally, however, in some patients, the lesion can arise in the macular region. An association between lesions resembling classic SC and tuberculosis was recognized as a possibly distinct clinical entity and named as tuberculous serpiginous–like choroiditis. The differentiation of this tuberculous entity from SC is critical because the treatment of the former with immunosuppressive drugs leads to several potential adverse effects, and such treatment can have devastating consequences because of the worsening of a concomitant tuberculous infection. Case presentantion A 31-year-old woman presented with unilateral decreased vision and a fundus examination consistent with macular serpiginous choroiditis. A non-reactor tuberculin skin test and normal thoracic CT scan ruled out tuberculosis. However, after 2 months of treatment with steroids and immunosuppressive drugs, the contralateral eye developed similar lesions, further raising the suspicions of ocular tuberculosis. We conducted QuantiFERON® TB Gold, which was positive; hence, antituberculous therapy was started on the patient. The lesions started healing within a few weeks. After 1 year of finishing the therapy, the lesions remained healed without any recurrence. Conclusions Macular serpiginous-like choroiditis may be the initial presentation of presumed ocular tuberculosis. Nevertheless, the correct diagnosis of this entity can be challenging and delayed by the imprecise results from the currently available methods.